Skin and not dorsal root stimulation reduces hypertonus in thoracic motor complete spinal cord injury: a single case report.

On demand and localized treatment for excessive muscle tone after spinal cord injury (SCI) is currently not available. Here, we examine the reduction in leg hypertonus in a person with mid-thoracic, motor complete SCI using a commercial transcutaneous electrical stimulator (TES) applied at 50 or 150 Hz to the lower back and the possible mechanisms producing this bilateral reduction in leg tone. Hypertonus of knee extensors without and during TES, with both cathode (T11-L2) and anode (L3-L5) placed over the spinal column (midline, MID) or 10 cm to the left of midline (lateral, LAT) to only active underlying skin and muscle afferents, was simultaneously measured in both legs with the pendulum test. Spinal reflexes mediated by proprioceptive (H-reflex) and cutaneomuscular reflex (CMR) afferents were examined in the right leg opposite to the applied LAT TES. Hypertonus disappeared in both legs but only during thoracolumbar TES, and even during LAT TES. The marked reduction in tone was reflected in the greater distance both lower legs first dropped to after being released from a fully extended position, increasing by 172.8% and 94.2% during MID and LAT TES, respectively, compared with without TES. Both MID and LAT (left) TES increased H-reflexes but decreased the first burst, and lengthened the onset of subsequent bursts, in the cutaneomuscular reflex of the right leg. Thoracolumbar TES is a promising method to decrease leg hypertonus in chronic, motor complete SCI without activating spinal cord structures and may work by facilitating proprioceptive inputs that activate excitatory interneurons with bilateral projections that in turn recruit recurrent inhibitory neurons.NEW & NOTEWORTHY We present proof of concept that surface stimulation of the lower back can reduce severe leg hypertonus in a participant with motor complete, thoracic spinal cord injury (SCI) but only during the applied stimulation. We propose that activation of skin and muscle afferents from thoracolumbar transcutaneous electrical stimulation (TES) may recruit excitatory spinal interneurons with bilateral projections that in turn recruit recurrent inhibitory networks to provide on demand suppression of ongoing involuntary motoneuron activity.

Correlation between hip muscle strength and the lower quarter Y-balance test in athletes following anterior cruciate ligament reconstruction.

INTRODUCTION: The lower quarter Y-balance test (YBT-LQ), which measures dynamic postural control, has been reported to be predictive of lower limb injuries in athletes. It requires subjects to control their body while maintaining a single-leg stance, which necessitates sufficient strength of the hip muscles to maintain stability. The purpose of the study was to investigate the correlation between the performance of the YBT-LQ and the hip abductor or extensor muscle strength in athletes following anterior cruciate ligament reconstruction surgery (ACLR). METHODS: Fifteen athletes with post-ACLR participated in this cross-sectional study. The participants completed the YBT-LQ, followed by isokinetic measurement of the hip abductor and extensor muscles of both the legs. The peak and average torque of the hip abductor and extensor muscles were tallied with the composite score of the YBT-LQ for each limb. RESULTS: No correlation was found between the strength of the hip muscles and the YBT-LQ composite score in both injured and non-injured limbs at all velocities except for the eccentric hip abductor and concentric hip extensor torques. The eccentric hip abductor average torque is strongly associated with the YBT-LQ (r = 0.663, p = 0.010) at a speed of 180°/s. The concentric hip extensor peak torque was weakly correlated with balance (r = 0.540, p = 0.046) at a speed of 180°/s. CONCLUSION: Our study demonstrated a positive correlation between the YBT-LQ and eccentric hip abduction and concentric hip extension at higher velocities. This shows the importance of implementing velocity-oriented rehabilitation in an athletic population following ACLR.

Effectiveness of instrument assisted soft tissue mobilization versus foam rolling on trigger point release in calf muscles.

BACKGROUND: Instrument assisted soft tissue mobilization and foam rolling are two techniques that have been proven effective in treating Myofascial Trigger Points, irrespective of the type of trigger point. However, little is known about the comparative effectiveness of Instrument assisted soft tissue mobilization and foam rolling. This study proposed to evaluate the effectiveness of either technique on plantar flexors trigger points, ankle dorsiflexion, and lower limb power present in the calf muscles in non-symptomatic patients. METHOD: Forty-two subjects with bilateral calf muscle tightness, at least one trigger point in the calf muscle, and fulfilling the inclusion criteria were randomly assigned to either of the groups. Group A was treated for gastrocnemius and soleus trigger points using Instrument assisted soft tissue mobilization and Group B was treated using the Foam Rolling method. Treatment was given every alternate day, a total of 3 sessions. Subjects were evaluated on 1st and 3rd sessions for pre-post differences of ankle dorsiflexion Range of motion in weight bearing and non-weight bearing position, pressure pain threshold for gastrocnemius trigger point 1(G1), 2(G2), and soleus point 1(S1) on both sides, and lower limb power. RESULT: Within group analyses, both groups had shown statistically significant results for all parameters except gastrocnemius trigger point 2 of foam rolling. For between group comparison foam rolling had a statistically significant result in non-weight bearing ankle dorsiflexion range of motion. CONCLUSION: Both Instrument assisted soft tissue mobilization and Foam rolling were equally effective for treating calf trigger points. But foam rolling was more effective in improving ankle dorsiflexion range of motion.

Unilateral dynamic balance assessment: The test-retest reliability of the OptoJump next drift protocol.

BACKGROUND: The OptoJump Next Drift Protocol is a test designed to assess unilateral dynamic balance. Participants are required to perform a series of unilateral jumps from which left/right and forward/back displacement (Drift) is calculated. OBJECTIVES: This investigation set out to establish the test-retest reliability of the OptoJump Next Drift Protocol. METHOD: Twenty-six participants performed the OptoJump Next Drift Protocol on two separate occasions. Drift Area and Drift Area as a percentage of total available jump area were calculated for each leg. RESULTS: Interclass Correlation Coefficients (ICC) indicated poor reliability for Drift Area and Drift Area as a percentage of total available jump area (right leg r = .44; left leg r = -0.20). However, 95% Limits of Agreement (LoA) suggested a stronger relationship. For Drift Area, between trial Mean Difference for the right leg was 50.87 cm2 (95% LoA = -227.57 - 328.87) and for the left leg it was 54.08 cm2 (95% LoA = -333.62 - 441.79). For Drift Area as a percentage of total available jump area, Mean Difference for the right leg was 0.56% (95% LoA = -2.44 - 3.65) and for left 0.60% (95% LoA = - 3.76-4.89). CONCLUSIONS: Based on the 95% LoA data, the authors suggest that the OptoJump Next Drift Protocol does offer an acceptable level of reliability.

Effects of upper limbs' neuromuscular electrical stimulation (NMES) superimposed to voluntary contraction added to a protocol of intradialytic leg cycle ergometer exercise, in muscle strength, functional capacity and quality of life of adult patients with CKD: a randomized clinical trial protocol.

OBJECTIVE: To investigate the effects of unilateral upper limbs' (ULM) neuromuscular electrical stimulation (NMES) superimposed on a voluntary contraction added to a protocol of intradialytic leg cycle ergometer exercise on muscle strength, functional capacity and quality of life of adult patients with chronic kidney disease (CKD). METHODS: This randomized controlled clinical trial will be carried out at a Brazilian University Hospital. The patients will be evaluated and randomly allocated to an intervention group (i.e., unilateral NMES on the upper limb without hemodialysis fistula for 20 min and leg cycle ergometer for 30 min) or a control group (i.e., unilateral NMES-Sham on the upper limb without hemodialysis fistula for 20 min and leg cycle ergometer for 30 min). The patients will be treated for 8 weeks, with three weekly treatment sessions totaling 24 sessions. MEASUREMENTS: ULM muscle strength, functional capacity, quality of life and also the feasibility, safety and patient adherence to the exercise protocol. All physical measurements will be collected by trained researchers before treatment (week 0) and at the end of treatment (week 9), always in the second hemodialysis session of the week. It will be used in an intention-to-treat analysis. RESULTS/CONCLUSIONS: The outcomes of this clinical trial protocol may help to know the possible benefits of unilateral ULM' NMES superimposed on a voluntary contraction added to a protocol of leg cycle ergometer for patients with CKD and to aid clinical decisions about future implementation or not of this technique (NMES) in intradialytic physical training programs.

The effect of acupuncture on exercise capacity in patients with COPD is mediated by improvements of dyspnea and leg fatigue: a causal mediation analysis using data from a randomized controlled trial.

BACKGROUND: Acupuncture is known to improve exercise capacity in patients with chronic obstructive pulmonary disease (COPD), but its mechanism remains unknown. Whether acupuncture improves exercise capacity in patients with COPD through alleviation of leg fatigue and dyspnea is examined by applying causal mediation analysis to previous trial data. METHODS: Sixty-two patients with COPD completed treatments with either real or placebo acupuncture once a week for 12 weeks. Walk distance measured using the 6-minute walk test and intensities of leg fatigue and dyspnea in the modified Borg scale were evaluated at baseline and after treatment. The intervention effect of acupuncture against the placebo acupuncture on two mediators, changes in leg fatigue and dyspnea, and whether they mediated improvements in walk distance, were analyzed. RESULTS: Linear regression analysis showed that the unstandardized regression coefficients [95% confidence interval (CI)] for the intervention effect by acupuncture were -4.9 (-5.8--4.0) in leg fatigue and -3.6 (-4.3--2.9) in dyspnea. Mediation analysis showed that when changes in leg fatigue were considered as a mediator, direct effect, indirect effect and proportion mediated were 47.1 m (95% CI, 4.6-85.1), 34.3 m (-2.1-82.1), and 42.1%, respectively, and when changes in dyspnea were considered as a mediator, they were 9.8 m (-32.9-49.9), 72.5 m (31.3-121.0), and 88.1%, respectively, and the effects of joint mediator were -5.8 m (-55.4-43.9), 88.9 m (32.7-148.5), and 107.0%, respectively. CONCLUSION: The improvement in exercise capacity by acupuncture is explained by changes in both leg fatigue and dyspnea.

Efficacy of Chinese and Western Medical Techniques in Treating Diabetic Foot Ulcers With Necrotizing Fasciitis of the Lower Leg.

To analyze and evaluate the clinical efficacy of Chinese and Western medical techniques in the treatment of severe diabetic foot ulcers complicated with necrotizing fasciitis of the lower leg and summarize the treatment experience of such patients to identify a new method of limb salvage treatment. A total of 46 patients with severe diabetic foot ulcers and necrotizing fasciitis of the lower leg were treated with such techniques as surgical debridement, bone drilling, open joint fusion, and microskin implantation. Wounds were treated with moisture-exposed burn therapy (a regenerative medical treatment for burns, wounds, and ulcers) and moisture-exposed burn ointment (a traditional Chinese medicine); underlying diseases were also treated effectively. The wound healing time, rate of high amputation, and mortality of these patients were summarized, and the clinical efficacy of such treatments was evaluated. Of the 46 patients enrolled, 38 patients were cured, with a cure rate of 82.61%. The average wound healing time was 130 ± 74.37 days. Two patients underwent high amputations, with an amputation rate of 4.35%, and 4 deaths occurred, with a mortality rate of 8.70%. The combination of Chinese and Western medical techniques in the treatment of severe diabetic foot ulcers complicated with necrotizing fasciitis of the lower leg not only effectively saved patients' lives and promoted wound healing but also greatly reduced the rates of high amputation and disability.

Therapeutic drug monitoring of ceftazidime/avibactam: why one leg is not enough to run.

BACKGROUND: Therapeutic drug monitoring (TDM) is becoming an increasingly recommended approach for assessing optimal pharmacokinetic/pharmacodynamic (PK/PD) target attainment of ceftazidime/avibactam. Some authors hypothesized that the PK/PD target attainment of ceftazidime/avibactam could be assessed by means of the TDM of solely ceftazidime, since avibactam concentrations might be extrapolated based on the fixed 4:1 ceftazidime-to-avibactam ratio present in the vial. The reliability of this hypothesis could be called into question if a wide interindividual variability in the ceftazidime-to-avibactam ratio would exist among patients. This study aimed to assess the distribution of the individual ceftazidime-to-avibactam ratios in relation to renal function in a cohort of adult patients who were treated with continuous infusion ceftazidime/avibactam and underwent TDM of both ceftazidime and avibactam. METHODS: Individual ceftazidime-to-avibactam ratio was calculated at each TDM assessment. Receiving operating characteristics (ROC) curve analysis was performed for testing the potential impact of renal function on ceftazidime-to-avibactam ratio variability. RESULTS: A total of 188 TDM assessments were collected from 107 patients. The ceftazidime-to-avibactam ratios ranged from 1.29:1 to 13.46:1. Seventy-seven out of 188 ceftazidime-to-avibactam ratios (41.0%) were >5:1, and 36 (19.1%) were >6:1. Patients without renal dysfunction had significantly higher proportions of ceftazidime-to-avibactam ratio >5:1 (59.3% versus 23.8%; P < 0.001) and >6:1 (32.1% versus 6.3%; P < 0.001) compared with those with mild-to-severe renal dysfunction. CONCLUSIONS: The findings may strengthen the contention that for properly assessing the PK/PD target attainment of ceftazidime/avibactam, both ceftazidime and avibactam concentrations should be measured, given the unpredictability of the ceftazidime-to-avibactam ratio occurring among patients.

Towards AI-Controlled Movement Restoration: Learning FES-Cycling Stimulation with Reinforcement Learning.

Functional electrical stimulation (FES) has been increasingly integrated with other rehabilitation devices, including rehabilitation robots. FES cycling is one of the common FES applications in rehabilitation, which is performed by stimulating leg muscles in a certain pattern. The appropriate pattern varies across individuals and requires manual tuning which can be time-consuming and challenging for the individual user. Here, we present an AI-based method for finding the patterns, which requires no extra hardware or sensors. Our method starts with finding model-based patterns using reinforcement learning (RL) and customised cycling models. Next, our method fine-tunes the pattern using real cycling data and offline RL. We test our method both in simulation and experimentally on a stationary tricycle. Our method can robustly deliver model-based patterns for different cycling configurations. In the experimental evaluation, the model-based pattern can induce higher cycling speed than an EMG-based pattern. And by using just 100 seconds of cycling data, our method can deliver a fine-tuned pattern with better cycling performance. Beyond FES cycling, this work is a case study, displaying the feasibility and potential of human-in-the-loop AI in real-world rehabilitation.

Medical device-related pressure injury from compression therapy.

The use of compression therapy is known to be effective in the management of patients with venous leg ulceration and is commonly recommended as a first-line treatment. A rare but known complication of compression therapy is pressure damage to the limb, also referred to as bandage damage, which should be categorised as a medical device-related pressure injury. Patients should receive a comprehensive, holistic assessment before any compression therapy is applied. Risk factors for compression therapy injury include peripheral arterial disease, older age, fragile skin, pronounced bony prominences or tendons, calf atrophy, foot drop, neuropathy/absent sensation, limited movement, cognitive impairment and receiving end of life care. Risks can be mitigated through a variety of approaches, and practitioners should be aware that these can change depending on the patient's condition. A community improvement initiative, illustrated with a case study, introduced a clinical pathway that can facilitate the identification and management of patients who are at risk of developing pressure injuries as a result of compression therapy.

The effects of the functional garment on the biomechanics during the single leg drop landing.

INTRODUCTION: A functional biomechanics garment (FBG) may help to prevent injury by improved kinematics during motion such as single leg drop landing (SLDL). The purpose of this study was to investigate the effects of the FBG on the biomechanics of SLDL. METHOD: Seventeen female university basketball players participated. Characteristics of the FBG were designed based on biomechanics during weight-loaded performance of human movement. The average values of lower limb kinematics and kinetics in the sagittal and frontal planes from 3 SLDL with and without FBG were measured and compared. RESULTS: The maximum varus angle of the knee showed a significant difference between the use of FBG (15.3 ± 15.1°) and without the use of FBG (5.9 ± 15.4°), the flexion angular displacement of the hip (with FBG, 21.5 ± 8.1°; without FBG, 24.0 ± 6.7°) between with and without FBG. The moment of the hip with FGB (1.1 ± 0.6 Nm) was significantly smaller than without FGB (1.4 ± 0.8 Nm). DISCUSSION: Regarding function of the FBG, the rigid part of the hip could counter the excessive adduction and flexion of the hip, and the elastic part of the thigh could support the varus moment when the elastic part stretched. Therefore, the subjects with FBG could control the frontal motion of the knee, which has a risk of knee injury, such as the dynamic valgus of the knee during the SLDL. CONCLUSION: Use of the FBG decreases dynamic knee valgus, which reduces risk of knee injury.

Comparison of dynamic and static balance among professional male soccer players by position.

PURPOSE: Balance is an important performance aspect of all athletes. The aim of this study was to compare static and dynamic balance in soccer players in different positions. METHODS: Forty youth and young adult professional soccer players were divided into four groups according to their playing positions: goalkeepers (GK), defenders (DF), midfielders (MF) and forwards (FW) (10 per position). Static and dynamic balance assessed on the dominant and non-dominant legs were measured using a force platform for 30s (static one-leg stand), and "Y Balance Test" (dynamic balance). RESULTS: GK exhibited greater ML static balance (less ML sway) compared with other players (p < 0.02-0.001). Moreover, results demonstrated better GK dynamic balance compared to DF and FW (p < 0.04-0.006). MF showed better dynamic balance than DF and FW (p < 0.019-0.007) and lower dynamic balance scores were found among DF and FW (p < 0.05). CONCLUSION: In conclusion, these results affirm position-specific balance performance with greater static and dynamic balance of GK and dynamic balance with MF. It is suggested that evaluation of balance and postural control performance should be considered a relevant part of the position-specific functional evaluation of soccer players.

Comparing right and left hamstring flexibility and its association to nonspecific lowr back pain among women of different age groups.

BACKGROUND AND OBJECTIVES: Decreased hamstring flexibility has been associated with LBP (lower back pain). Increased tightness or shortening of hamstring muscle may cause pelvis imbalance or tilt and create instability and increase LBP risk. This study was conducted to pinpoint the differences between right and left hamstring length and their association to LBP in Israeli adult and elderly women. METHODS: N = 109 women which were divided into two groups: Adult group, 41 women (aged 45-60) and older group, 68 women (aged 60-75), with LBP that exercise regularly (minimum twice weekly) were selected based on inclusion criteria. Hamstring flexibility was measured using the Passive Straight Leg Raise test and Sit and Reach test, and LBP was measured using the Oswestry Disability Index (OS), the Roland-Morris questionnaire (RM), and a personal information questionnaire. FINDINGS: Findings indicate a statistically significant difference (p < .05) in hamstring flexibility between right and left legs in PSLR test, with the left being shorter than the right. A significant negative correlation was found between hamstring shortening to function in OS and RM questionnaires in the older group, no significant correlation was found between left -right hamstring flexibility differences and reduced function with LBP in the OS and RM questionnaires. CONCLUSION: s: Hamstring shortening in adult and elderly women exists despite regular exercise. Future studies must be incorporated to improve hamstring flexibility with emphasis on balance of left and right legs to examine how this will affect LPB reports and compare women who exercise versus women who do not.

Lower limb hyperthermia augments functional hyperaemia during small muscle mass exercise similarly in trained elderly and young humans.

NEW FINDINGS: What is the central question of the study? Ageing is postulated to lead to underperfusion of human limb tissues during passive and exertional hyperthermia, but findings to date have been equivocal. Thus, does age have an independent adverse effect on local haemodynamics during passive single-leg hyperthermia, single-leg knee-extensor exercise and their combination? What is the main finding and its importance? Local hyperthermia increased leg blood flow over three-fold and had an additive effect during knee-extensor exercise with no absolute differences in leg perfusion between the healthy, exercise-trained elderly and the young groups. Our findings indicate that age per se does not compromise lower limb hyperaemia during local hyperthermia and/or small muscle mass exercise. ABSTRACT: Heat and exercise therapies are recommended to improve vascular health across the lifespan. However, the haemodynamic effects of hyperthermia, exercise and their combination are inconsistent in young and elderly people. Here we investigated the acute effects of local-limb hyperthermia and exercise on limb haemodynamics in nine healthy, trained elderly (69 ± 5 years) and 10 young (26 ± 7 years) adults, hypothesising that the combination of local hyperthermia and exercise interact to increase leg perfusion, albeit to a lesser extent in the elderly. Participants underwent 90 min of single whole-leg heating, with the contralateral leg remaining as control, followed by 10 min of low-intensity incremental single-leg knee-extensor exercise with both the heated and control legs. Temperature profiles and leg haemodynamics at the femoral and popliteal arteries were measured. In both groups, heating increased whole-leg skin temperature and blood flow by 9.5 ± 1.2°C and 0.7 ± 0.2 L min-1 (>3-fold), respectively (P < 0.0001). Blood flow in the heated leg remained 0.7 ± 0.6 and 1.0 ± 0.8 L min-1 higher during exercise at 6 and 12 W, respectively (P < 0.0001). However, there were no differences in limb haemodynamics between cohorts, other than the elderly group exhibiting a 16 ± 6% larger arterial diameter and a 51 ± 6% lower blood velocity following heating (P < 0.0001). In conclusion, local hyperthermia-induced limb hyperperfusion and/or small muscle mass exercise hyperaemia are preserved in trained older people despite evident age-related structural and functional alterations in their leg conduit arteries.

Source-Based EEG Neurofeedback for Sustained Motor Imagery of a Single Leg.

The aim of the study was to test the feasibility of visual-neurofeedback-guided motor imagery (MI) of the dominant leg, based on source analysis with real-time sLORETA derived from 44 EEG channels. Ten able-bodied participants took part in two sessions: session 1 sustained MI without feedback and session 2 sustained MI of a single leg with neurofeedback. MI was performed in 20 s on and 20 s off intervals to mimic functional magnetic resonance imaging. Neurofeedback in the form of a cortical slice presenting the motor cortex was provided from a frequency band with the strongest activity during real movements. The sLORETA processing delay was 250 ms. Session 1 resulted in bilateral/contralateral activity in the 8-15 Hz band dominantly over the prefrontal cortex while session 2 resulted in ipsi/bilateral activity over the primary motor cortex, covering similar areas as during motor execution. Different frequency bands and spatial distributions in sessions with and without neurofeedback may reflect different motor strategies, most notably a larger proprioception in session 1 and operant conditioning in session 2. Single-leg MI might be used in the early phases of rehabilitation of stroke patients. Simpler visual feedback and motor cueing rather than sustained MI might further increase the intensity of cortical activation.

[Regularity of meridian-acupoint reactions of foot three yin meridians in primary dysmenorrhea and secondary dysmenorrhea patients].

OBJECTIVE: To observe the meridian-acupoint reactions of foot three yin meridians in primary dysmenorrhea(PD) and secondary dysmenorrhea(SD) patients, so as to summarize the rules of meridian-acupoint reaction and acupoints selection. METHODS: Thirty-five patients with PD (PD group), 34 patients with SD (SD group) and 35 healthy subjects (healthy group) were recruited. The compression method was used to examine the lower leg segment of the foot three yin meridians. Positive reactions(palpable skin changes, including cords, nodules, depressions) and tenderness of meridians and acupoints were recorded. The visual analogue scale (VAS) was used to evaluate the tenderness severity of acupoints. RESULTS: Compared with the healthy group, the probability of positive reactions and tenderness in foot three yin meridians were higher in PD and SD groups (P<0.01,P<0.05). Compared with the PD group, the probability of positive reactions in Spleen and Liver Meridians were higher in the SD group, with higher probability of tenderness in Liver Meridian(P<0.05). The probability of positive reactions and tenderness in the Spleen Meridian of PD and SD groups was significantly higher than that in the Kidney Meridian (P<0.01), while the probability of tenderness in the Spleen Meridian of the PD group was significantly higher than that in the Liver Meridian (P<0.05). Positive reactions and tenderness were concentrated at Yinlingquan (SP9), Diji (SP8) and Sanyinjiao (SP6) of Spleen Meridian and Xiguan (LR7) and Ligou (LR5) in Liver Meridian of PD and SD groups. In comparison with the PD group, the probability of positive reactions, tenderness and VAS score of SP8 and LR5 of the SD group were higher (P<0.05, P<0.01). CONCLUSION: The positive reaction occurs most frequently in the Spleen Meridian, followed by the Liver Meridian, and least frequently in the Kidney Meridian. The acupoints with positive reaction are different between PD and SD, which suggests that the Spleen Meridian acupoints should be the main acupoints when treating the two kinds of dysmenorrhea, and acupoints should also be selected according to the meridian and acupoint examination results.

Inguinal intranodal lymphangiography reveals a high incidence of suprainguinal lymphatic disease in patients with leg edema undergoing stenting for symptomatic chronic iliofemoral venous obstruction.

OBJECTIVE: Recent studies have emphasized the important role lymphatics play in the drainage of interstitial fluid and edema prevention. Although the infrainguinal lymphatics have been studied in some depth, with patterns of pathology identified, such data above the groin are sparse, especially for patients with phlebolymphedema. The present study attempts to evaluate the status of lymphatic flow above the inguinal ligament in patients presenting with edema and undergoing stenting for symptomatic chronic iliofemoral venous obstruction (CIVO). METHODS: A total of 31 lower limbs that underwent pedal lymphoscintigraphy for leg edema and subsequent stenting for symptomatic CIVO formed the study cohort. Each limb underwent intranodal lymphangiography of an ipsilateral inferior inguinal lymph node (10 mL of lipiodol) at the time of stenting. Fluoroscopic visualization of lipiodol transit was performed at 20, 40, and 60 minutes and 3 hours after injection. Enumeration of the lymph nodes and lymphatic collector vessels from above the inguinal ligament to L1, visualization of the thoracic duct, the time delay to visualization of the thoracic duct, and pathologic changes to the thoracic duct when present were all evaluated. These anomalies were independently scored, with the scores combined to generate a total suprainguinal score (range, 0-3). This score was then compared to the limb's lymphoscintigraphically derived infrainguinal score (total infrainguinal score range, 0-3) using the t test and Spearman correlation. The clinical outcomes (grade of swelling, venous clinical severity score) after stenting were appraised. RESULTS: Of the 30 patients (31 limbs), 18 were women, with left laterality noted in 23 limbs. A nonthrombotic iliac vein lesion occurred in 9 limbs and post-thrombotic syndrome in 22 limbs. Of the 31 limbs, 24 (77%) had suprainguinal lymphatic disease (SLD), with 22 of the 24 limbs having severe SLD and 2, mild SLD. When SLD was compared with infrainguinal lymphatic disease, 6 limbs (19%) had the same degree of involvement above and below the groin (1 with normal and 5 with severe disease), 17 limbs (55%) had more severe SLD, and 8 limbs (26%) had more severe infrainguinal lymphatic disease. Three limbs with normal pedal lymphoscintigraphic findings had severe SLD. The Spearman correlation coefficient for the comparison of SLD and infrainguinal disease in the same limb was 0.1 (P = .69). At baseline, the limbs with severe SLD had the same degree of leg swelling and venous clinical severity score as the limbs with absent to mild SLD (P > .1) with similar improvements after stenting (P > .4). Seven limbs underwent complex decongestive therapy (all with severe SLD and concomitant severe infrainguinal disease in one) to treat significant residual leg edema, with improvement. CONCLUSIONS: SLD appears to be common in patients with leg edema undergoing stenting for symptomatic CIVO. Such disease appears to affect the thoracic duct more commonly. Although patients with persistent or residual leg edema after stenting can benefit from complex decongestive therapy, further workup in the form of inguinal intranodal lymphangiography and targeted intervention might need to be considered for those who do not benefit from such therapy. Further study is warranted.

The immediate effect of unilaterally applied lumbar mobilisations on the passive straight leg raise and ninety-ninety test in asymptomatic adults: A randomised crossover trial.

OBJECTIVES: This study assessed the immediate effect of unilateral posterior-anterior lumbar mobilisations on trunk and lower limb flexibility in asymptomatic individuals. STUDY DESIGN: Randomised cross-over trial. PARTICIPANTS: Twenty-seven participants (age = 26.0 years ±6.4) with no current or recent history of lower back or leg pain/surgery completed the study. MAIN OUTCOME MEASURES: Participants attended two sessions, receiving either grade 3 ('treatment') or grade 1 ('sham') unilateral spinal mobilisations. Outcome measures (modified-modified Schober's test [MMST], ninety-ninety test [NNT], and passive straight-leg raise [PSLR]) were assessed immediately before and after (post-1 and post-2) the intervention. An instrumented hand-held dynamometer was used to measure the change in NNT and PSLR joint angle (deg) and passive stiffness (Nm/deg) pre- and post-intervention. RESULTS: The mean change in PSLR angle at the first (P1) and maximal (P2) point of discomfort following the treatment was 4.8° and 5.5°, and 5.6° and 5.7°, larger than the sham at post-1 and post-2, respectively. There was no effect of the treatment on the PSLR at P1 or P2 for the contralateral limb at either timepoint. There was no effect of the treatment on MMST distance, NNT angle or passive stiffness, or PSLR passive stiffness, for either limb. CONCLUSIONS: Immediate effects of unilateral posterior-anterior lumbar mobilisations in asymptomatic individuals are isolated to treatment side and limited to a small increase in PSLR range, with no change in lumbar motion or the NNT test.

The effect of perturbation training with and without applying the dry needling on leg muscles in patients with chronic ankle sprain.

INTRODUCTION: Ankle sprain is a common musculoskeletal injury that leads to recurrent instability. Repeated ankle sprain can be a mechanism for creating trigger point. Proper treatment of trigger points, in addition to preventing recurrence of sprains, may reduce pain and improve muscle function. This improvement can be the result of preserving the surrounding tissues from excessive pressure. OBJECTIVE: Investigate the added value of dry needling into perturbation training protocol for chronic ankle sprain. DESIGN: Randomized clinical trial; assessor-blind; before and after comparison. SETTING: Treatment of patients referred to the institutional rehabilitation clinics. MAIN OUTCOME MEASURE(S): Functional assessment with FAAM questionnaire score, Pain with NPRS scale, ankle instability severity with Cumberland tool. METHODS: Twenty-four patients with chronic ankle instability participated in this clinical trial and were randomly divided into two groups. Intervention was 12 sessions in which one group received only perturbation training and the other group received perturbation training along with dry needling. Repeated measures ANOVA was used to investigate the effect of treatment. RESULTS: Data Analysis showed significant difference in NPRS and FAAM and Cumberland score before and after treatment in each group (P < 0.001). Comparison of the results between the groups did not show any significant difference (P > 0.05). CONCLUSION: The findings showed that adding dry needling technique to the perturbation training does not have greater effects on the pain and function of patients with chronic ankle instability.

Effects of eccentric-emphasized leg curl intervention on muscle strength imbalance markers in professional soccer players during pre-season.

BACKGROUND: The effects of strength training on muscle strength imbalance are unclear in professional soccer players. As a result, this study examined the effects of an 8-week strength training program comprising eccentric-emphasized prone leg curl adjusted according to the individual strength imbalance status. METHODS: Ten professional soccer players (26.0 ± 3.6 yrs) participated in the study. Players who had a ≥ 10% contralateral imbalance in knee flexors eccentric peak torque (n = 6) performed two additional repetitions per set in the low-strength limb (high-volume, HV) compared to the high-strength limb (low-volume, LV). Isokinetic concentric knee extension and concentric and eccentric knee flexion peak torque (PT) and derived contralateral imbalances and conventional and functional hamstring-to-quadriceps ratios (H:Q) were assessed at baseline and after 8 weeks. Differences at baseline were assessed using paired-sample T-tests, and a two-way (limb x time) repeated measures analysis of covariance (ANCOVA) for changes over time. RESULTS: A significant improvement in the eccentric knee flexion PT was observed in both limbs after 8 weeks (P < 0.05), with greater effects observed in the HV limb (25.0 N m, 95% CI: 15.1-34.9 N m). Significant decreases were also observed in the contralateral imbalances from concentric knee extension and flexion and eccentric knee flexion PT (P < 0.05). Differences were not observed in concentric knee extension and flexion PT (P > 0.05). CONCLUSIONS: A short-term eccentric-emphasized leg curl intervention adjusted by the initial knee flexors eccentric strength was an efficient method to improve knee flexors strength imbalance in professional soccer players.